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Neurology – Hemiplegia, Hemisensory Loss (With or Without Aphasia)
Whiteboard Animation Transcript
with Ted Wein, MD
Acute Hemiplegia is generally a sign of a serious medical condition most likely of vascular origin; it should prompt immediate investigations and management as symptoms and signs may remain indefinite if irreversible damage and infarction occurs.
It is important to quickly rule out or treat a stroke, as “time is brain”.
Here is what you need to know when someone presents to the emergency room with hemiplegia and/or hemisensory loss with or without aphasia.
One – General Assessment
Start with the ABC’s, place the patient on full vital monitoring, and check their glucose.
Two – Get a History
It is important to know the time the patient was last awake and symptom free. Prepare for possible thrombolysis if symptom onset is known to be under 4.5 hours. Ask questions to rule out conditions mimicking stroke, such as seizure history, migraines, hypoglycemia, and conversion disorder.
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Three – Investigations and Imaging
Order a non-contrast CT head scan immediately to rule out hemorrhage and to assess the extent of infarct as well as vascular imaging either by CTA or MRA and carotid Doppler. Order an ECG to rule out atrial fibrillation, and send out a CBC, electrolytes, creatinine, PTT/INR, and blood glucose.
Four – Management
Thrombolysis therapy can be given within 4.5 hours of symptom onset, providing there are no contraindications for their use. If thrombolysis therapy is not given, anti-platelet therapy should be given as aspirin and anti-coagulation with IV heparin is recommended if ECG confirms atrial fibrillation.
Mechanical thrombectomy may be performed up to 6 hours from symptom onset in patients with symptoms of stroke and a documented occlusion of the proximal middle cerebral artery.
Additionally, it’s important to NOT lower blood pressure unless hypertension is severe, to lower temperature if febrile, to avoid hyperglycemia, and to prevent complications from occurring. This includes NPO if dysphagia is present, DVT prophylaxis, and initiate rehabilitation early. Also place head of bed at 30 degrees and began IV
Five – Additional Investigations
Additional investigations to confirm etiology can be considered after general management have been initiated. Confirming the etiology of the stroke is key for secondary prevention strategies.